At BCA, we have the distinct pleasure of working with billers, coders, and clinicians from coast to coast. We’ve listened carefully to the struggles and needs of each organization and have responded by expanding our offerings. In order to efficiently answer the many questions we receive, we’re using this platform. Please browse the posts below for answers to your common questions and updates to information that is essential to your revenue cycle. If you don’t see your question answered here, feel free to submit it for consideration.
RevU Recent Posts
- PCMH Recognition to Improve Patient Outcomes: Medical Directors and Quality Teams
Medical and quality directors are important in promoting clinical and operational excellence. Patient-Centered Medical Home (PCMH) recognition provides a chance to transform care delivery, prioritize patient engagement, and achieve high-quality outcomes. How can PCMH be used as a framework for value-based care? Let’s discuss the advantages of adhering to PCMH standards and the strategic actions… Read more: PCMH Recognition to Improve Patient Outcomes: Medical Directors and Quality Teams - Leveraging Patient-Centered Medical Home (PCMH) Recognition for Quality ImprovementClinics and healthcare providers are always seeking ways to enhance quality outcomes and patient satisfaction. The Patient-Centered Medical Home (PCMH) recognition offers a comprehensive, patient-focused approach that prioritizes care coordination, patient engagement, and improved health outcomes. PCMH certification is not just a milestone for quality care; it is a transformative process that reshapes the dynamics… Read more: Leveraging Patient-Centered Medical Home (PCMH) Recognition for Quality Improvement
- Engaging Providers in Value-Based Care: A Financial Perspective for Revenue Cycle TeamsFor finance teams and revenue cycle management, the transition to value-based care (VBC) doesn’t just affect clinical outcomes—it directly impacts billing accuracy, revenue, and the organization’s overall financial health. To succeed in VBC, revenue cycle teams must work closely with clinicians to improve documentation, ensure accurate coding, and leverage financial incentives tied to quality metrics.… Read more: Engaging Providers in Value-Based Care: A Financial Perspective for Revenue Cycle Teams
- Engaging Providers in Value-Based Care: A Guide for Medical Directors and CliniciansThe shift to value-based care (VBC) is one of the most significant changes in healthcare delivery today. For medical directors and clinicians, it’s not just about managing day-to-day patient care but about adapting to new models and prioritizing patient outcomes over volume. While VBC can seem daunting, it offers a tremendous opportunity to improve the… Read more: Engaging Providers in Value-Based Care: A Guide for Medical Directors and Clinicians
- Engaging Providers in Value-Based Care: A Roadmap for Quality TeamsIn today’s healthcare environment, we all know how challenging it can be to get clinicians fully on board with value-based care (VBC). The transition from volume-based models can feel overwhelming, especially when integrating new workflows and meeting performance metrics. However, our quality teams play a critical role in guiding providers through this process—creating an atmosphere… Read more: Engaging Providers in Value-Based Care: A Roadmap for Quality Teams
- Optimizing Quality and Revenue Cycles with Population Health DataFor quality and revenue cycle managers, leveraging population health data to close care gaps and enhance revenue cycle processes is essential to meeting value-based care goals, improving patient outcomes, and maintaining financial sustainability. Population health management is increasingly important in primary care, especially for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs). This… Read more: Optimizing Quality and Revenue Cycles with Population Health Data
- Maximizing ROI and Improving Patient Outcomes Through Population Health Management: A Strategic Guide for Financial and Medical LeadershipIn today’s healthcare environment, leaders at Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) face a dual challenge: improving patient outcomes while managing resources effectively to achieve financial sustainability. Population health management has emerged as a critical tool for meeting these objectives, allowing healthcare organizations to allocate resources strategically, focus on high-risk patients, and manage chronic conditions while lowering long-term costs.
- Maximizing Patient Outcomes through Population Health ManagementDiscover advanced strategies for using population health data to close care gaps, manage high-risk patients, and improve chronic disease outcomes. Learn actionable steps for building a sustainable population health management program that drives better care and lowers costs.
- Problem List Clean-UpProblem list clean-up is a necessary task, but who has time to devote to it? And even if you clean it up, a quick problem list import from an information-sharing program can have you right back in the mess you just cleaned up! We most often consider this a provider task, but have you given… Read more: Problem List Clean-Up
- Do the new ICD-10-CM codes for obesity classes improve provider comfort with labeling weight disorders?I’ve noted a few trends recently when educating medical professionals on coding guidelines for weight disorders. Many push back on the instructions to pair a weight disorder with a BMI, primarily in the name of provider-patient relationship. This pairing is essential for accurate quality scores and reimbursement, yet it can be seen as a sensitive… Read more: Do the new ICD-10-CM codes for obesity classes improve provider comfort with labeling weight disorders?
- Streamlining Coding Processes Through Quality ImprovementFor coders and revenue cycle managers, quality improvement (QI) is not only about enhancing patient care; it also plays a crucial role in streamlining coding processes and reducing claim rejections. This post explores how quality initiatives can benefit coding practices and improve the efficiency and accuracy of revenue cycle management. How Quality Improvement Efforts Can… Read more: Streamlining Coding Processes Through Quality Improvement
- Aligning Clinical and Operational Quality Initiatives for Better Patient OutcomesAligning clinical and operational quality initiatives is critical for medical directors and quality managers to achieve better patient outcomes. In this article, we’ll explore strategies for integrating quality improvement (QI) across departments and the pivotal role of leadership in fostering a culture of continuous improvement. Importance of Aligning Clinical and Operational Quality Initiatives In healthcare,… Read more: Aligning Clinical and Operational Quality Initiatives for Better Patient Outcomes
- Creating an Integrated Quality Improvement FrameworkIn today’s healthcare landscape, the importance of quality improvement (QI) cannot be overstated. An integrated approach that unites clinical, operational, and administrative teams can significantly elevate patient outcomes, streamline processes, and reduce costs. Developing a unified QI framework is essential for any healthcare organization striving for excellence. Developing a Unified Approach: Integrating Quality Improvement Efforts… Read more: Creating an Integrated Quality Improvement Framework
- Building a Culture of Continuous Improvement in FQHCs and RHCsFostering a culture of continuous improvement is fundamental to the long-term success of Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs). In these healthcare settings, where resources can often be limited, and the need for quality care is paramount, creating an environment where staff consistently seek better ways to deliver care can significantly… Read more: Building a Culture of Continuous Improvement in FQHCs and RHCs
- Ensuring Compliance and Quality: Best Practices for Conducting Effective Documentation AuditsDiscover essential strategies for effective documentation audits to maintain compliance with regulatory standards and enhance patient care quality.
- Empowering Residents and Medical Students with Essential Coding EducationOne of the most frequent responses we hear when BCA provides coding education to medical professionals is, “I wish I’d had this sooner!” This sentiment reflects a significant gap in medical education: the lack of comprehensive training in coding and documentation.
- Why FQHCs and RHCs Should Care About Risk Adjustment: Taking Comprehensive Care to the Next LevelDiscover the importance of risk adjustment for FQHCs and RHCs. Learn how accurate documentation and financial strategies can enhance patient care, ensure compliance, and achieve financial stability with the help of BCA.
- The Role of Continuous Education in Enhancing Healthcare Delivery in FQHCs and RHCsContinuous education is key to improving healthcare delivery in Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs). Learn how ongoing training leads to better patient care, increased efficiency, and enhanced compliance. Discover valuable resources and strategies to support continuous learning.
- Leveraging Data Analytics to Improve Financial and Clinical Outcomes in FQHCs and RHCsDive into the power of data analytics in healthcare! Learn how FQHCs and RHCs leverage data to boost financial performance and enhance patient outcomes.
- The Importance of Credentialing and Payer Enrollments in Ensuring Quality and Compliance for FQHCs and RHCsDiscover how to optimize credentialing and payer enrollment for FQHCs and RHCs! Ensure compliance, quality care, and cost-effective solutions.
- Optimizing Billing and Coding for Maximum Reimbursement in a Value-Based WorldLearn how to optimize billing and coding for FQHCs and RHCs with best practices, staff training, and practical tools. Maximize reimbursement and ensure compliance in value-based care with expert insight from BCA, Inc.
- Strategies for Successful Value-Based Contracting in FQHCs and RHCsDiscover essential strategies and negotiation tips for value-based contracting in Federally Qualified Health Centers and Rural Health Centers. Learn from expert insights to drive financial and clinical benefits for your organization.
- How Value-Based Care is Redefining Quality Metrics in FQHCs and RHCsDiscover how FQHCs and RHCs can thrive under value-based care by focusing on patient outcomes, preventive care, and chronic disease management. Learn strategies for improving care delivery and achieving financial success.
- Navigating the Shift: Value-Based Care for FQHCs and RHCsExplore the strategic transition from fee-for-service to value-based reimbursement in Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs). Learn how to enhance patient outcomes and ensure financial sustainability with BCA Consulting. #ValueBasedCare #FQHC #RHC #HealthcareTransformation
- Navigating the Financial Future of FQHCs in a Post-COVID-19 Funding EnvironmentAs the financial landscape shifts in 2024 with the diminishing of COVID-19 relief funds, FQHCs nationwide face significant challenges in maintaining financial stability. With inflation demanding increasing wages, rising healthcare costs, and evolving payment trends, finance professionals must adopt strategic budgeting practices to navigate this new reality effectively. The Current FQHC Funding Environment FQHCs have… Read more: Navigating the Financial Future of FQHCs in a Post-COVID-19 Funding Environment
- PHE ChangesWith the public health emergency (PHE) declared to have ended on May 11, 2023, now is the time to update any current policies or practices that may have been implemented in your organization due to Covid-19. One of the most notable updates allows remote communication flexibilities to remain in place for an additional 90 days,… Read more: PHE Changes
- BCA Summary of Diagnosis Coding Updates for April 2023The International Classification of Diseases, Tenth Revision, ClinicalModifications (ICD10CM) is updated April 1st and October 1 st every year. Theseupdates provide opportunities to review the current HIPAA mandated diagnosiscoding guidelines, encourage team members to update the accuracy ofpatient’s chronic problem list and determine necessary educationalopportunities for the entire team This April 2023 update includes 42… Read more: BCA Summary of Diagnosis Coding Updates for April 2023
- Bonnie Hoag ScholarshipIn honor of our founder, Bonnie Hoag, BCA dedicates an annual scholarship award for one worthy recipient to our Comprehensive Coding Education Program (CCEP). The recipient of the Bonnie Hoag Scholarship will receive a full tuition scholarship to our CCEP program that prepares attendees to sit for either their CPC or CCS-P credential. Bonnie’s passion… Read more: Bonnie Hoag Scholarship
- 2023 E/M Guideline Changes WebinarJanuary ushers in significant guideline revisions bringing welcome relief to the current coding drudgery. Clinicians will no longer have to worry whether a patient qualifies for inpatient vs. observation status when selecting their service code. We will see the removal of “bean-counting” requirements for history and exam elements, with guidelines aligning with the outpatient service changes we saw… Read more: 2023 E/M Guideline Changes Webinar
- Comprehensive Coding Education ProgramComprehensive Coding Education Program Elevate your expertise with our comprehensive, self-paced on-demand course tailored for aspiring nationally certified professional coders. Geared specifically toward success in Federally Qualified Health Center (FQHC) settings, this program delves into ICD-10-CM, Current Procedural Terminology (CPT), and HCPCS Level II coding, augmented by the occasional medical terminology, anatomy, and physiology instruction… Read more: Comprehensive Coding Education Program
- How Accurate is Your Diagnosis Reporting?Time to Focus on the Importance of ICD10CM Quality. As you are preparing for your 2023 production data to be analyzed, don’t forget about the importance of accurate ICD10CM reporting. It’s been common knowledge for years that ICD10 codes represent medical necessity for services provided to patients, however, quality reporting has only recently started to… Read more: How Accurate is Your Diagnosis Reporting?
- BCA’s 99211 FactsheetWith a current reimbursement rate of $23.53, it is evident that reporting 99211 can bring additional revenue into your practice. Reporting just five 99211 encounters per week could result in over $6,100 per year. The following guidelines can help assure you maintain compliance and receive the revenue you deserve for the services you may already… Read more: BCA’s 99211 Factsheet
- UDS Quality Measures and HRSA complianceDid you know that one of the compliance pieces of an FQHC is their quality program? Some clinics may refer to this as their CQI or QIQA committee/team. Part of this compliance program is based on accurate data in patient records, which coders can often assist with collecting. This data is then required to be… Read more: UDS Quality Measures and HRSA compliance
- BCA Monday Morning MinutesHave a minute? Check out BCA Monday Minutes! Most recent Monday Morning Minute – Episode 18: Combination Codes
- UDS Reporting UpdateAs UDS reporting deadlines have surfaced, it’s important to know the HRSA Health Center Program FAQs about UDS reporting have recently been updated. Fun Fact: Beginning with the 2023 UDS reporting cycle, HSRA will also accept patient-level report data using Fast Healthcare Interoperability Resources. The following HRSA FAQ page https://bphc.hrsa.gov/datareporting/reporting/faqs is a great resource to visit common… Read more: UDS Reporting Update
- BCA Coding ServicesSimplify Your Coding Practices while Maximizing Revenue At BCA, we always want to stay ahead of our client’s needs. With the ever-changing landscape of the healthcare industry and ongoing demands for FQHCs, we’ve found that there’s an immense need to support our Community Health Center partners with claims coding support. This is due in part to… Read more: BCA Coding Services
- AMA’s CPT 2022 UpdatesThe American Medical Association (AMA) has released the 2022 Current Procedural Terminology (CPT®) code set, which incorporates a series of 24 vaccine-specific codes that are the model for efficiently reporting and tracking immunizations and administrative services against the coronavirus (SARS-CoV-2). The COVID-19 vaccine and administration codes are among 405 editorial changes in the 2022 CPT code set,… Read more: AMA’s CPT 2022 Updates
- BCA No Surprises Act (NSA) Starter ToolkitWith the No Surprises Act (NSA) set to take place for physician services come January 1, 2022, the BCA Team has put together a “No Surprises Act (NSA) Starter Toolkit” designed to help physician offices kick start implementation of this new rule. See the attached documents to get your team started today! Contact Us at… Read more: BCA No Surprises Act (NSA) Starter Toolkit
- No Surprises Act Roundtable EventIn November 2021, the No Surprises Act, was signed into law. This new law is designed to protect consumers from surprise medical bills related to “surprise” and “balance” billing, but what does this mean for our physician practices? We had a great discussion at our roundtable event on 12/1 and continue to learn more about… Read more: No Surprises Act Roundtable Event
- November is American Diabetes Month!According to the American Diabetes Association, one in three people in the United States have prediabetes. Check out their website to be aware how diabetes may affect you as well as some helpful tools to reduce your risk. Check out this simple diabetes diagnosis coding scenario that may occur in the office setting: Follow up… Read more: November is American Diabetes Month!
- October is Breast Cancer Awareness Month: What better time than now to buff up your cancer documentation and reporting?!According to the World Health Organization (WHO), breast cancer is the most common cancer globally (as of 2021) and the second most fatal cancer in women. We encourage those that fall within the screening guidelines to get your mammogram scheduled today. In order to assure appropriate coding for these conditions, it is critical to recognize causes, stages and… Read more: October is Breast Cancer Awareness Month: What better time than now to buff up your cancer documentation and reporting?!
- Managing UDS MeasurementsPeter Drucker famously said, “What gets measured gets managed.” We have spent some time recently exploring UDS Quality Measures, but where do we even begin to look at this data? How can we improve on data if we don’t know where to start? We are going to dive into an amazing place in this post, the world of HRSA data! … Read more: Managing UDS Measurements
- Improving Population Health, One Patient at a TimeWe spend quite a bit of time looking at quality measures. Aside from our UDS reporting, why do we care about quality measures? The days of E&M reimbursement are soon going to be in the rearview mirror and value-based care is where our future lies. Because several of these measures are based on the eCQMs (Electronic Clinical Quality Measures), which are standardized by NCQA, UDS reporting also becomes very important to payers. Currently, many organizations live in… Read more: Improving Population Health, One Patient at a Time
- Telehealth Policy Updates as of 08/23/2021The Center for Connected Health Policy (CCHP) released current Telehealth Policy updates that break down the most common areas of focus right now. These updates include licensing laws, prescribing requirements, reimbursement policies and the best resources to track each. Although we have summarized some of these important updates from CCHP for your reference below, be sure to visit CCHP’s website for… Read more: Telehealth Policy Updates as of 08/23/2021
- Proposed Updates for 2022 Uniform Data Systems (UDS) Reporting: What You Need to Know NowHealth Resources and Services Administration (HRSA) has recently released proposed updates to quality of care measures for 2022. This update is set to align clinical quality measures (CQMs) with the versions of the Centers for Medicare and Medicaid Services (CMS) electronic-specified clinical quality measures (eCQMs) designated for the 2022 reporting period. Data-driven quality improvement efforts and full optimization of electronic health record (EHR) systems are strategic… Read more: Proposed Updates for 2022 Uniform Data Systems (UDS) Reporting: What You Need to Know Now
- Visit for Paperwork: Are these services medically necessary?The following scenario comes across our schedules/lists from time to time and is often reported with an Evaluation and Management (E/M) code (99202-99215) based on time. Example: 44 year old male here for completion of paperwork, scanned copy into chart. ROS: None recorded. Exam: None recorded. A/P: Completion of paperwork and total face-to-face patient time 15 minutes. When a patient presents without complaints, the visit likely does not… Read more: Visit for Paperwork: Are these services medically necessary?
- Coder’s Influence on UDS Quality OutcomesIn FQHCs nationwide, UDS reporting is often thought of once a year and is generally a bad word muttered by CFOs and IT staff. However, it doesn’t have to be so difficult or segregated to such a small reporting team. Many teams are relying heavily on the reporting generated by their EMR system, which may… Read more: Coder’s Influence on UDS Quality Outcomes
- Emphasis on Health Equity in 2021Health equity means ensuring that everyone has the chance to be as healthy as possible. However, factors outside of a person’s control, such as discrimination and lack of resources, can prevent them from achieving their best health. Working toward health equity is a way to correct or challenge these factors. As defined by Executive Order by… Read more: Emphasis on Health Equity in 2021
- Proposed ICD-10-CM ChangesThe ICD-10-CM Coordination and Maintenance Committee met on March 9th and 10th to discuss proposed changes for 10/1/2021. Use this link to access the “Proposal Packet” for details about the requests, https://www.cdc.gov/nchs/icd/icd10cm_maintenance.htm April 9th is the deadline for public comments. The committee will meet again in September. Here are a few highlights of the requested… Read more: Proposed ICD-10-CM Changes
- Best Practice Documentation for NursesQ: Can you provide some information on best practice documentation for nurses when completing orders that are not performed on the date they were ordered? A: This is a great question and the nurses in your clinic may also be a resource to answer your question. While documentation may occasionally be viewed as being burdensome,… Read more: Best Practice Documentation for Nurses
- Undiagnosed New ProblemQ: In the new 2021 E/M Guidelines what constitutes as an undiagnosed new problem? A: CPT defines an undiagnosed new problem with uncertain prognosis as “A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. An example may be a lump in the breast.”… Read more: Undiagnosed New Problem
- Lost Connection During Audio-Visual Telehealth VisitQ: If a telehealth encounter begins with audio-visual but they must convert to audio-only for the rest of the visit, how do you determine which code to use when the payer accepts the phone code 99441-99442 and the video code is 99212-99215? A: During the current Public Health Emergency, a variety of telehealth policies have… Read more: Lost Connection During Audio-Visual Telehealth Visit
- Two Clinicians Complete One EncounterQ: I have a patient encounter where 2 different providers working in our urgent care clinic completed orders for the same patient encounter. I rarely see this type of documentation and I believe it happened because of shift-change during the encounter. The first provider completed the majority of the visit, ordered a prescription and signed… Read more: Two Clinicians Complete One Encounter
- Established Patient Follows Provider to New ClinicNote: For a new Medicare FQHC patient, see – Medicare FQHC Patients Follow Provider to New FQHC. Q: I have a new provider and several of her patients have followed her to our clinic. Should these patients be coded as new or established at their initial visit in our clinic? A: This question was answered… Read more: Established Patient Follows Provider to New Clinic
- Medicare FQHC Patients Follow Provider to New FQHCNote: This question is specific to the Medicare FQHC new patient definition. For non-Medicare FQHC patients, see – Established Patient Follows Provider to New Clinic. Q: We have recently had providers join our team from other clinics and their patients have followed them. Can you tell me where I can find the guidelines for whether… Read more: Medicare FQHC Patients Follow Provider to New FQHC
- Coding per MDM When Time is DocumentedQ: A provider completed an E/M in 25 min. The documentation supports Moderate MDM, does the service need to be down coded to a 99213 due to the documented time? A: Under the new E/M guidelines, code assignment is per Time or MDM for codes 99202-99215. Time does not need to be documented when coding… Read more: Coding per MDM When Time is Documented
- E/M Coding in Mental HealthQ: My question pertains to the new E/M guidelines in the setting of mental health. Under Amount and/or Complexity of Data for codes 99205 and 99215, it states that 2 of the 3 categories must be met to count Data as Extensive. For services provided in mental health we find we are only meeting 1… Read more: E/M Coding in Mental Health
- Principal Care Management, G2064, G2065, in the FQHC.Q: My physician mentioned there is a new care management code that FQHCs can report for patients with one chronic condition. Is that correct? If so, what is the new code? A: Your physician is most likely referring to codes G2064 and G2065, Principal Care Management (PCM). The codes were new in 2020 but were… Read more: Principal Care Management, G2064, G2065, in the FQHC.
- Personal interpretation of radiology test during an E/MQ: Are there documentation suggestions for a provider’s personal interpretation of an x-ray under the new E/M guidelines when awaiting the radiologist’s formal read? A: This a great question and a topic that requires unambiguous documentation. Otherwise, it may read as though the information was taken from the radiology report or as though the global… Read more: Personal interpretation of radiology test during an E/M
- Documentation of ordered testQ: In order to be able to count a test (ex: lab, x-ray), must the order be documented in the office note or just anywhere in the chart for that day to count? A: Based on review of available payer information including Medicare, the treating/ordering physician or qualified healthcare professional (QHP) must clearly document, in the… Read more: Documentation of ordered test
- MDM and Problems AddressedQ: Under MDM noting that a problem is being managed by another provider does not count as the problem being managed during the visit. But what if I, the patient’s physician, note that I reviewed that provider’s recommendations with the patient to ensure they were compliant, understood the instructions and other possible treatment options? A:… Read more: MDM and Problems Addressed
- FQHC Funding ConsiderationsThe past year has presented many challenging situations for all businesses, and FQHCs have been hit especially hard with the COVID-19 pandemic. Throughout this time, they’ve seen shortages in PPE, staffing, and a demand for care like none other in their history. Fortunately, much funding has been made available to FQHCs to assist with their… Read more: FQHC Funding Considerations
- Prolonged time codes 99417 and G2212Q: I’m confused with time-based coding and counting prolonged time and differences between 99417and G2212. Please help! A: Both codes are designed to be reported only when using time-based coding according to the E/M guidelines and only with codes 99205 and 99215. The conundrum is related to application differences between the AMA and CMS. The… Read more: Prolonged time codes 99417 and G2212
- Counting a test for MDMQ: My provider ordered a diagnostic test today, however, it will not be reviewed with the patient until the follow-up visit next week. Is it correct that I can count the order today for a Data point in the MDM and when it’s reviewed next week, count another Data point for the review? A: Ordering… Read more: Counting a test for MDM
- Counting unique tests under the new guidelinesQ: Please help clarify the Data section of MDM under the new CPT/AMA guidelines and counting unique tests. For example, the provider ordered a chest x-ray, an MRI and a CT, how is this counted? And what if the provider ordered three different lab tests? A: Great questions! Let’s first review the instructions in the… Read more: Counting unique tests under the new guidelines
- Telehealth without the patient presentQ: If a provider performs a telehealth visit (audio/visual) for a pediatric patient, but only the mom was present during the service, may we bill the E/M? A: Telehealth has certainly changed the landscape in the past year. Think of telehealth as a delivery mechanism. If the clinician were to see mom for an appointment… Read more: Telehealth without the patient present
- Does a problem count as a problem addressed if it is for refill onlyQ: If the provider sees a patient for a specific illness and refills a medication for a chronic condition that was not addressed, does the moderate risk for medication management still apply or is it strictly related to the condition addressed during the visit? A: In short, no. You should not count prescription drug management… Read more: Does a problem count as a problem addressed if it is for refill only
- What constitutes a well-documented record? A coder’s perspectiveQ: The new AMA guidelines for 2021 state that the nature and extent of the history and/or physical examination is determined by the clinician reporting the service. With the history and exam requirements being removed from code selection, what standards should we encourage when reviewing medical records? A: A well-documented record has always been important,… Read more: What constitutes a well-documented record? A coder’s perspective
- Diagnosis coding for coexisting diabetes, hypertension, and chronic kidney diseaseQ: My clinician is asking which condition should be coded as causal to chronic kidney disease – hypertension or diabetes – when both are present. Specifically, clinicians are asking, “Why do we need to add the cause of CKD? We cannot be sure whether the cause was HTN versus Diabetes versus heart failure. We don’t… Read more: Diagnosis coding for coexisting diabetes, hypertension, and chronic kidney disease
- History of Present Illness in 2021Q: Should we continue to require HPI information for each problem in 2021? A: Answer: While we are certainly thankful for the 2021 guideline changes, we should not be so quick to put HPI and exam on the shelf. Codes 99202-99215 are defined as requiring medically necessary history and exam. While the extent may be… Read more: History of Present Illness in 2021
- Prevention and illness management in the Same encounter for 2021Q: If a provider sees a patient for a wellness service or preventive exam (e.g., annual well woman exam) and also addresses concerns or chronic conditions, we’ve previously held the problem-oriented E/M to a lower level due to the comprehensive nature of the wellness service and difficulty carving out sufficient history and exam to support… Read more: Prevention and illness management in the Same encounter for 2021
